=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124038732
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPORTS IMAGING CENTERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2006
-----------------------------------------------------
Last Update Date | 04/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 VIRGINIA AVE
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-466-5050
-----------------------------------------------------
Fax | 772-467-1003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 VIRGINIA AVE
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-466-5050
-----------------------------------------------------
Fax | 772-467-1003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. DEBY YYONNE DUKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-466-5050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | HCC8031
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------